Presentation Transcript

1. Maximizing Integration of clinical pharmacist in Chronic Disease Management VA model v1

   Right Care Initiative Presentation March 4, 2013 Anthony P. Morreale, Pharm.D., MBA, BCPS, FASHPAssistant Chief Consultant for Clinical Pharmacy Services and Healthcare Delivery Services ResearchPharmacy Benefits Management Services (119)Department of Veterans Affairs
2. PRESENTATION OVERVIEW Focus on Cardiovascular outcomes to align with Right Care and San Diego Goals preventing strokes and heart attacks. Overview of VA Medical Home initiative known as Patient Aligned Care Teams (PACT), implementations and progress. VA initiative to utilize Clinical Pharmacist at the top of their license to Manage Chronic Disease. Lesson learned and challenges that can be applied broadly external to the VA. Group Challenge on how some of the concepts presented can be applied to the Right Care initiative.
3. VA HEDIS Scores

4. Describe the VA Version of the Medical Home Model = Patient Aligned Care Teams (PACT)

5. Other Team Members Clinical Pharmacy Specialist: ± 3 panels Clinical Pharmacy anticoagulation: ± 5 panels Social Work: ± 2 panels Nutrition: ± 5 panels CaseManagers Trainees Integrated Behavioral Health Psychologist ± 3 panels Social Worker ± 5 panels Care Manager ± 5 panels Psychiatrist ± 10 panels For each parent facility Health Promotion Disease Prevention Program Manager:1 FTE Health Behavior Coordinator: 1 FTE My HealtheVet Coordinator:1 FTE The Patient’s Primary Care Team
6. Changes in Primary Care
7. Measurement – Can We Measure Improvement PACT Compass Panel Management Continuity Access Coordination Engagement and Satisfaction Patient Satisfaction CAHPS Patient Centered Medical Home Survey Primary Care Almanac Diabetes Hypertension Congestive Heart Failure Clinical Performance Measures Prevention Chronic Disease Management Employee Satisfaction surveys PACT Recognition Survey PACT Personnel Survey Home Builder Scores
8. Improvements in Home Builder Domains VHA Average Oct-09 69% Jul-11 80% Ref: American College of Physicians Medical Home Builder
9. National Changes since PACT Implementation(July 2010-July 2012)
10. PACT Implementation Dashboard – 7 metrics * Meets FY12 Performance Measure
11. Dashboard Metric Penetration
12. PACT Workload Trends Better Performance
13. Urgent/Emergent Care 43% Better Performance
14. Admission Rates Represents avoidance of 36,279 admissions 47% Better Performance
15. PACT Personnel Survey, Summer 2012 Better Performance
16. Training Status, August 2012
17. Effect of Training on PACT Metrics
18. PACT Training, Burnout and Job Satisfaction
19. More than half my time is spent each week on work that could be done by someone with less training
20. SPECIALTY PACTS HOME BASED PRIMARY CARE (HBPC) HIV SPINAL CORD INJURY WOMEN’S HEALTH GERIATRICS HOMELESS

21. VA initiative to utilize Clinical Pharmacist at the top of their license to Manage Chronic Disease.

22. Clinical Pharmacy Model Vision: Bridging the Gap Between Primary Care and Specialty Care Patient Complexity, Health Status, Needs Specialty Care Patient Aligned Care Team Clinical Pharmacy Specialist Specialist Clinical Nurse Specialist Teamlet & Expanded Team Clinical Pharmacy Specialist Coordination of Care Disease/Cohort Management Management of Care Reference: A. Morreale June 2011
23. Clinical Performance Dashboards
24. Knowing Our Baseline VA had a robust clinical pharmacy program across the country but we no means to describe it. How many and what types of Pharmacists and Technicians did we have? What sites have strong programs and which sites had opportunities for improvement? What clinical pharmacy metrics can be used to characterize sites? How many clinical pharmacists do we have and in what settings do they work in? How many patients do they see and how many interventions or visits do they perform?
25. Baseline (cont) Under VA Policy Pharmacists can have a Scope of Practice (SOP) with prescriptive privileges. What did we know about that? How many pharmacists have a SOP in the VA? What clinical areas are most commonly covered? What areas are innovative and unique? What standards are in place to ensure consistency in the SOP process? How are evaluations performed of the clinical pharmacy specialist and the clinical outcomes tracked?
26. National Clinical Pharmacy SharePoint Site New Clinical Pharmacy SharePoint Site has been created http://vaww.infoshare.va.gov/sites/vapharmacyinformatics/ClinicalPharmacy/default.aspx?PageView=Shared Started populating with Medical Home and currently working on all other specialty areas like Hep C, HBPC, oncology, nephrology, etc. Content for over 50 job areas includes: Business plans / staffing justifications Peer review examples Competencies Scope of practice Literature sources Functional statements and performance statements Research and Quality improvement project ideas Staffing calculators Data collection sources Contacts and SharePoint Managers Links to useful sites such as VACO library, Workload Capture, VHA tools
27. Create a Uniform System for Scope of Practice Develop field guidance on Scope of Practice (SOP) Create a uniform system for Scope of Practice Outline routine pharmacist activities that do and do not need a SOP Revise VHA Directive 2008-043 Scope of Practice for clarity Quantify how many clinical pharmacists in the VA have a SOP Assure impact of SOP are adequately reflected in pharmacist qualification standards Define differences between a Clinical Pharmacist and CPS Review standardization of Scope of Practice and Competency for incorporation into Pharmacist Qualification Standards
28. Guidance on Implementation of Patient Aligned Care Teams (PACT) Created SharePoint Site and national email group to share ideas Created Pharmacy Business Rules for sites to follow Advisory Members have participate in numerous VISN PBM conferences and meetings, as well as regional collaboratives, to describe the role of the CPS in PACT Tracked new FTEE that Pharmacy Services have received across the VA to support PACT Conducted Consultation Team Training for Primary Care Services Participating in development of a national handbook on PACT
29. Pharmacy Business Rules for PACT Reference: VA PACT Business Rules v2 February 2012
30. Educational Programming for Leaders: Boot Camps Educated all levels of leadership on our transformational plans at National Meeting in Denver. Over 400 participants focused heavily on implementation, maintenance, and growth of clinical pharmacy programs Created a National Live Meeting Series to support ongoing efforts in transforming practices Launched Four Regional Clinical Pharmacy “Boot Camps” in 2011 that trained over 300 Clinical Pharmacists on 7 core chronic primary care diseases Established National Volunteer Group of over 200 pharmacists and technicians to work on “boot camp” curriculum and to help maintain and develop a more robust SharePoint site, expert panels, and ongoing support and newsletters
31. Did Boot Camps Work? Pre-Post Boot CampPharmacist with Scope of Practice
32. Systems Redesign Task Group Focusing on optimizing the availability and efficient use of pharmacist, pharmacy technicians, automation, and contracted services resources to improved productivity and effectiveness. Create data collection tools to assess staffing, get field involvement, surveys, etc. Explore ways to evaluate existing programs Existing resources can be streamlined and redeployed using proven systems redesign principles that have not been universally applied. A few examples include: Identify all potential areas where pharmacy technicians can be transformed into new practices to fully assume the dispensing roles Changes in National, Regional and local Policies Use of Automation Moving all dispensing functions to technicians Using employees at the highest level of their training Eliminate unnecessary tasks Contracting, pre-made, pre-packaged Leveraging innovations from each site Benchmarking and metrics to measure cross sectional performance
33. WHAT HAVE WE DISCOVERED IN OUR JOURNEY TO TRANSFORM TO NEW PRACTICES?
34. Facts We have a little more than 7500 pharmacists and 4100 Technicians in the system Their activities were diverse and not well organized There are many practices that are highly advanced but have never been shared outside the local system There is broad, but inconsistent use of technicians, policies and practices
35. Pharmacists with a Scope of Practice (n=2654)
36. Pharmacists With a Scope of Practice – Growth Over Time
37. Percentage of Time Spent Working Under Scope of Practice
38. Demographics of VA Pharmacists
39. Pharmacist SOP by Disease State
40. Scope of Practice Trends
41. Clinical Pharmacy Encounter Growth Reference: VA SharePoint Metrics site Dec 2011
42. Proving Transformation to New Practice Models is all about Outcomes!!
43. Issues with Outcomes Studies
44. Pharmacist vs. PCP Managed CV Factors Geber J, Parra D, Beckey NP, Korman L. Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting. Pharmacotherapy. 2002 Jun;22(6):738-47
45. VA San Diego Diabetes Management Clinic *C.Morello June 2010 n=60
46. Pharmacist Managed ESA Study CPS use of ESA is safer based on number of patients staying within FDA recommended Hb range of 10-12 (71% vs.. 57%) and the number of Hb that exceeded 12 (10% vs.. 22%) CPS followed their patients more closely based on number of Hb and iron studies, which might explain better achievement of Hb goals on lower doses of medications Cost-Effectiveness of Pharmacist-Managed Erythropoiesis-Stimulating Agents Clinics: A Multicenter Study in Veterans with Non-Dialysis Chronic Kidney Disease. Aspinall 2011
47. Pharmacists Achieve Results with Medications Documentation (PhARMD) Project Measuring Interventions and Outcomes System Wide Using a Pharmacotherapy Intervention Tracking Tool
48. PBM PhARMD Project Tool Design PBM designed a clinical reminder tool for roll-out by end of calendar year. Project aligns with VHA Transformational Initiatives Tool provides documentation of clinical interventions related to medication management by Clinical Pharmacy Specialists (CPS) across VHA, as non-physician providers. CPRS tools provide the ability to document Pharmacotherapy interventions which have demonstrated: Potential to reduce harm to patients Potential cost avoidance to healthcare system CPS demonstrate the ability to document clinical interventions and therapeutic achievements for specific disease states
49. PBM PhARMD Clinical Reminder ToolTool Design and Use The CPS documents interventions made and when goals achieved
50. PBM PhARMD Pharmacotherapy Reminder ToolTool Design and Use
51. PBM PhARMD ProjectDefining Metrics and Reports CPPO Corporate Data Warehouse (CDW) database house metrics Initial metrics defined by PBM PhARMD Project workgroup, further refinement ongoing Staging tables and initial report parameters in SQL created for report generation Dashboards developed Desire to have reports fluid and able to move between metrics easily, provide site level data along with individual CPS and patient specific data Awaiting additional security and site report access on CDW
52. PBM PhARMD ProjectMetrics and Reports Available Total Number of Disease state Interventions per Clinical Pharmacy Specialist (CPS) Total Number of Additional Pharmacotherapy Interventions per Clinical Pharmacy Specialist (CPS) Average number of interventions per CPS visit Cost avoidance associated with specific pharmacotherapy interventions Number (%) of patients at goal by facility Time to goal for disease state (visits and days) by facility Cost of disease state specific medications per CPS Time to goal  Review of Treatment to Goal for disease specific interventions (IN DEVELOPMENT)
53. PBM PhARMD Expansion Pilot ResultsApril 2012 to January 2013 Tool utilized by 314 pharmacists at 26 VA sites
54. Linking Cost Avoidance to CPS InterventionsDevelopment of a Cost Benefit Model Development of cost benefit model underway Lee et.al. provides base for cost avoidance of interventions made by clinical pharmacists in VHA Analysis needed when the pharmacist functions as the prescriber as seen in PhARMD project Aldridge et.al. showed that 7% of interventions made in ER had potential to cause harm. Lee et.al. AJHP 2002;59:2070-2077
55. PBM PhARMD ProjectFuture Implications for Use Use of tool nationally has multiple implications for the profession of pharmacy and practice within VHA Opportunities include: National Benchmarking of pharmacy interventions and outcomes National, VISN and Local Cost justification of new and existing pharmacists Comparison of pharmacy interventions in VHA to other healthcare organizations Use in OPPE process for Scope of Practice Creation of Clinical Pharmacy Staffing tools and models Identification of best practices for more rapid sharing of information Identification in potential gaps in care that may exist at facilities Marketing the impact of clinical pharmacy care at the facility, VISN, National levels
56. What Type of Pharmacists Do We Need? Is a Pharm.D. degree with its clinical training good enough to do many tasks? Do they need to have a residency? Is Board Certification a necessary skill? Do we have time to wait to get individuals with these skills? Are there ways to train people internal to the system to assure they have the knowledge, skills and abilities to do the job? Do those with advanced education outperform those without?
57. Questions We would Like To Answer Years of Experience vs. BCPS vs. residency – do younger tend to have more degrees? Do they get better outcomes? Difference geographically or similar Are there practice setting differences (specialty vs. primary care) based on residency BCPS? Do generalists achieve similar outcomes compared to specialists (e.g. anticoagulation, Diabetes) What are the contributions of trainees (residents and students) in improving outcomes? Does the school or residency you were trained at make a difference in outcomes?
58. National Implementation Challenges
59. National Implementation Challenges (cont)
60. New Projects and Priorities for 2013:Practice Based Changes

61. ARE SIMILAR FORCES HAPPENING OUTSIDE THE VA?

62. Clinical Pharmacist Outcomes –Kaiser Literature Examples
63. Collaborative Practice Agreements (CPAs)10 - Opportunities Under ACO arrangements
64. Walgreen by the Numbers 7600 Stores on the best corners in America 67% of US population lives within 3 miles of a Walgreens 70,000 providers, mostly pharmacist 26,000 pharmacists are certified in immunizations 728 Take Care Clinics 119 “Medical Campus” Pharmacies

65. Regulatory & Political Change would make a huge difference

66. The CPS as a Health Care Provider Currently Pharmacists are not recognized in the Social Security Act (SSA) or CMS as Health Care Providers, practitioners, or Non‐Physician Practitioners (NPPs)3 The following health care professionals are recognized as providers by the Social Security Act:3,9 physician assistants, nurse practitioners, certified nurse midwives, clinical social workers, clinical psychologists, and registered dieticians / nutrition professionals CMS final Rule- May 2012 - New regulations allow hospitals to expand definition of medical staff to include PAs, APRNs, and pharmacists to perform all functions within their scope Payment for services not addressed. True implications are not clear
67. The CPS and Independent Practice (IP) In a recent letter of public support for the report titled Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General, 2011, Dr. Regina Benjamin stated the following… Health leadership and policy makers should further explore ways to optimize the role of pharmacists to deliver a variety of patient-centered care and disease prevention, in collaboration with physicians or as part of the healthcare team. Utilization of pharmacists as an essential part of the healthcare team to prevent and manage disease in collaboration with other clinicians can improve quality, contain costs, and increase access to care. Recognition of pharmacists as health care providers, clinicians and an essential part of the health care team is appropriate given the level of care they provide in many health care settings. Compensation models, reflective of the range of care provided by pharmacists, are needed to sustain these patient oriented, quality improvement services
68. Technology Implications Health in the Palm of Your Hand Examples AliveCor – FDA approved electrocardiogram Dr. Mole app iHealth BP5 – wireless blood pressure cuff Digfit – Fitbit Zeo sleep sensor iBGStar – blood glucose monitor will evolve Wireless thermometers Smart Scales – body weight ICU on wrist device Cellscope – iPhone otoscope & dermascope Cell microscope – allow uploading, used in foreign countries Portable Echo –Vscan instead of stethoscope iRhythm – holter alternative in a patch Tricoder – Xprize Implications Lower cost Widespread availability in doctors office with no need for delays or referrals Virtual encounters Immediate patient feedback
69. IMPLICATIONS FOR OUR INITIATIVES
70. Discussion Section - Right Care Substantial data exists that Clinical Pharmacist can improve care in Chronic disease states as proven by VA, Kaiser and other capitated, managed care models. In these settings they have made the pharmacist a mid-level provider or work under current state collaborative practice agreements. How can and should this data be used to push for engaging our under utilized pharmacist workforce. What can be done to get CMS to designate pharmacists as providers so that their documented positive services can be paid for. Since systems like VA & Kaiser don’t bill for Pharmacy Services but rather have justified paying them by achieving better outcomes why can ACO’s, medical groups and others accomplish the same by directly hiring pharmacists? What models and data, similar to that collected by the VA, can be centralized to demonstrate outcomes achieved by Pharmacist on the teams? How do we educate the providers about the value of the pharmacist as a team member rather than as a threat to their practices or income?
71. Discussion Section - Right Care (cont) Will Physician Shortages; growing demographics of elderly; and more insured needing care increase opportunities for pharmacist as providers? MTM Services in the retail environment are exploding and businesses like Walgreens have changed their entire business model from distribution to MTM. Lower trained individuals, including pharmacy technicians, are being worked to the top of their license so what are the implications for Pharmacist graduating today? What are the implications of technology, like cell phones & EMR’s, to make information more readily available at at various points of care including retail pharmacies?

72. CONTACT INFO

    Anthony P. Morreale, Pharm.D., MBA, BCPS Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Delivery Services Research Pharmacy Benefits Management Services (119) Department of Veterans Affairs anthony.morreale@va.gov